부산대학교 도서관

Background: Pharmacotherapy is crucial in current medical practices, yet drug-related problems threaten patients' health. Pharmacist-led clinical pharmaceutical services (CPS) have been proven to reduce these problems. However, evidence-proven services in research settings cannot be directly implemented in real-world settings due to contextual differences. Therefore, developing service models tailored to the local context and scientifically evaluating their effectiveness is essential to expand local CPSs. Objectives: This study aims to develop and evaluate a CPS model at the National Taiwan University Hospital, and it includes the following three research objectives: 1. Develop an integrated medication management model (IMM) based on current evidence to reduce drug-related problems in hospitalized patients and establish an evaluation plan. 2. Evaluate the clinical effectiveness of the IMM model for patient care. 3. Evaluate the impact of the IMM model on healthcare professionals' (HP) perceptions of CPSs and their intention to collaborate with pharmacists and explore the mechanisms behind the impact. Methods: To systematically develop and evaluate a CPS model, this study adopts the following research methods: 1. We formed a research team and adopted the following steps to develop the IMM model and its evaluation plan: literature review, problem definition, intervention model development, standard process establishment, and setting evaluation indicators. The model was piloted in one medical center ward to evaluate its impact on patient care and interprofessional collaboration. 2. We conducted an interrupted time-series study, aggregating clinical data of monthly admissions from the study wards into observational units and comparing the changes in monthly observations before and after implementing the IMM model. The primary outcome was the mean number of medication error (ME) reports. The following clinical outcomes were also evaluated: mean number of daily inpatient prescriptions, mean number of daily self-prepared medications, median daily medication costs, mean antibiotic use days, mean length of stay, extended stay rate, ICU admission rate, and mortality rate. Segmented regression analysis was used to assess the level and slope changes in outcome indicators after implementing the IMM model. We also conducted sensitivity and subgroup analyses. 3. We employed a sequential explanatory mixed methods design. First, through questionnaire surveys, we assessed the impact of the IMM on HPs' intentions to collaborate with pharmacists. Subsequently, semi-structured interviews and thematic analysis captured the HPs' experiences with the model. Finally, we integrated the quantitative and qualitative findings to interpret the mechanism of the impact of the IMM. Results: This study developed an IMM model and evaluated its effectiveness, with the main findings as follows: 1. Based on the literature review, we have selected three evidence-based CPSs, medication reconciliation, medication review, and ward-based pharmacist services, encompassed in the IMM model. The model provides service at all stages (admission, hospitalization, and pre-discharge) of a patient's hospital stay. Additionally, we established a logic model of the IMM model based on the Theory of Change to formulate evaluation indicators. 2. After implementing the IMM model, there was a significant increase in the mean number of ME reports (level change: 1.02, 95% confidence interval [CI]: 0.68 to 1.35, p＜ 0.001), with a notable rise in reports of omission or medication discrepancy, inappropriate drug choices, inappropriate routes or formulation, and not-in-benefit package. Additionally, there was a significant reduction in the mean number of daily inpatient prescriptions for patients aged ≥75 years (level change: -1.78, 95% CI: -3.06 to -0.50, p= 0.009). However, other indications did not show statistically significant changes. 3. Fifty-eight HPs completed the questionnaire, indicating that HPs from the intervention ward had a higher intention to discuss medication-related issues with pharmacists. Eleven HPs were interviewed, and they stated having better working relationships with pharmacists, experiencing more effective CPSs, and noting improved communication with pharmacists. The integration of quantitative and qualitative findings revealed that the critical mechanism of the IMM in promoting collaborative relationships is the integration of regular pharmacists into medical practice, which familiarizes HPs with pharmacists' roles, improves communication, and enables pharmacists to identify HPs' needs. Conclusion: We developed an IMM model grounded in evidence-based CPSs tailored to our specific context. This model is designed to minimize drug-related problems in hospitalized patients and improve overall care quality. Evaluation studies have shown that the IMM model notably increases the detection of medication errors and decreases medication usage in elderly patients. Following its implementation, there has been an enhancement in communication and collaboration between pharmacists and other HPs. Pharmacists are actively involved and engage directly with the medical team, improving service quality and deepening HPs' appreciation of pharmacists' roles. These results can guide other healthcare facilities. However, the study was limited by the small number of participants and the range of patient groups involved. Future research should assess the model's impact across various settings and conduct thorough pharmacoeconomic research to determine its financial effectiveness.